Fully funded health care - your rights
NHS Continuing Healthcare (fully funded)
http://www.counselandcare.org.uk/helping-you/guides/allguides/
Continuing healthcare: should the NHS be paying for your care?
Continuing healthcare – understanding the assessment process:
The above information/guidance sheets are extremely useful and the source of much that follows.
Key points:
High profile cases, notably the Coughlan case and particularly the Grogan case in 2006, drew attention to the fact that Local Authorities were using widely varying interpretations in their assessments for continuing healthcare. To end confusion and possible unfairness, the NHS drew up a national framework which became effective from October 2007. This framework lays down national criteria to be uniformly applied by all Strategic Health Authorities or Primary Care Trusts (PCT) in
Eligibility depends on whether a person's primary need is a health need - not just the severity of the condition, rather the type of care required to meet that need. Care needs must be at a level requiring 24 hour care. They will also be of a complex and changeable nature requiring the supervision of a health professional.
First step is a screening process using the NHS continuing healthcare “check list”. After that, the person may be referred for a full assessment. The fact of referral does not indicate that funding will be granted. It is only a first step. A full assessment would be carried out by a multi-disciplinary team (MDT) using the national Decision Support Tool (DST), very fully-explained in the above-referenced Counselandcare documents (and in Age Concern Fact sheet 20) which assesses the individual in 11 “domains”, behaviour, mobility, etc. If the needs do not fit neatly into any of the categories, the team should still determine and record the extent of the need and take it into consideration.
If a full assessment is deemed unnecessary at the “check list” stage, that decision and the reasons for it should be fully explained. The individual can challenge the decision with the PCT. It is possible to request a full assessment from the PCT, and to ask to see the paperwork when it has been completed, including the DST. According to the National Framework, “the PCT should give this request due consideration, taking into account all the information available including additional information from the individual or carer”.
Once a person has been referred for a full assessment for NHS Continuing healthcare, an individual or individuals should be identified to coordinate the whole process and should be responsible for the case until the decision about funding has been reached.
Although the DST ensures consistency, it alone does not determine eligibility. The healthcare professionals' experience and professional judgement also play a part. Once the MDT has come to agreement about eligibility, it makes a recommendation to the PCT. If the PCT does not follow the recommendation, then it must very clearly state its reasons and why this is an exceptional case.
It is important to note that the National Framework clearly states “Financial issues should not be considered as part of the decision about an individual’s eligibility for NHS Continuing Healthcare, and it is important that the process of considering and deciding eligibility does not delay treatment or appropriate care being put in place”. Finance officers should not be part of any decision-making panel.
If the MDT does not consider the person to be eligible for continuing healthcare, they should indicate the need, if any, for registered nursing care. The person should also be given clear information about his/her right to challenge the decision and the review process.
The time between referral for a full assessment and the notice of the decision about funding should not take more than 2 weeks in most cases.
The Community Care (Delayed Discharges, etc) Act 2003 states that every patient should be considered for assessment for NHS continuing healthcare before being discharged from hospital.